Provider Demographics
NPI:1750450722
Name:BERGEN, FREDRICK R (LMT)
Entity Type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:R
Last Name:BERGEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 FEDERAL POINT RD
Mailing Address - Street 2:
Mailing Address - City:EAST PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32131-4329
Mailing Address - Country:US
Mailing Address - Phone:386-328-2225
Mailing Address - Fax:
Practice Address - Street 1:120 S PALM AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4140
Practice Address - Country:US
Practice Address - Phone:386-325-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL46239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist